Wednesday, April 26, 2006

Your Truth: Decision Making Power

The following ethical scenario was proposed by reader JP.

As is custom, please read the scenario, share your thoughts or recommendations in the comments section and in a few days I will post a follow-up detailing the actual outcome in a related scenario.

Ms. Baker is a 84 year old woman with end-stage renal disease. She has been dependent on dialysis for the past ten years. She is currently in the hospital in the intensive care unit for sepsis (a bacterial infection in her blood). She also has a number of other co-morbidities including COPD (chronic obstructive pulmonary disease) and coronary artery disease.

When you walk into the room, the dialysis nurse pulls up to the bedside with the dialysis machine. As it appears, Ms. Baker tells you, "I am so miserable. It is so unfair that I have been so sick. Do you know the meaning of misery?"

The notes in her chart say that the family and the patient have decided on a DNR (do not resucitate) code status and have been made aware of her poor prognosis. You notice on the monitor that Ms. Baker's blood pressure is only 84/43. This is a very low pressure and the dialysis will likely drop it lower.

As the health care provider, you accept the responsibility for ensuring Ms. Baker is aware of her options. Accordingly, you say, "Ms. Baker, you can refuse dialysis at any time. It's actually a very peaceful way to go. You just fall asleep and don't wake up again."

Ms. Baker looks contemplative and asks, "Is that so?"

You assure her it is.

Ms. Baker looks thoughtful for a moment more. "Well, I want dialysis today."

When you leave the bedside, you search out the patient's children. When you find them, you explain to them the converation you had with the patient and why - she seemed miserable; her prognosis (as they know) is very poor and she should understand what her options are. The family is very angry that you have had this conversation with their mother and go so far as to tell you never to visit the patient again.

Some questions for your consideration:

1. Should patients be informed of their options?
2. Should families have the right to withold information from a patient?
3. How might you handle this situation from here?

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